Organization
OPEN AND WIDE MRI, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARDNER BARTROM (PRESIDENT)
(765) 228-4660
Entity
Organization
Contact information
Practice address
3050 WINDSOR CT, ELKHART, IN 46514-5555
(574) 266-9222
(574) 266-9333
Mailing address
PO BOX 338, LA FONTAINE, IN 46940-0338
(765) 228-4660
(765) 228-4660
Taxonomy
Speciality
Code
Description
License number
State
2471M1202X
Magnetic Resonance Imaging Radiologic Technologist
Primary
20590
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000275391
BCBS
IN
01
—
14506
PHP
—
05
—
1604490821
—
MI
05
—
200415560A
—
IN
Enumeration date
12/07/2005
Last updated
01/08/2024
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